Medical Negligence Archives

Newborn baby boy’s death due to hospital neglect

Posted on 16 February 202130 March 2025 by Sarah O'Sullivan

An Inquest conducted by the Hertfordshire Coroner Service has concluded that aspects of the events leading up to the sad death in hospital of Eddie Coffey, a one-day-old baby boy were so unsatisfactory that they amounted to neglect.

The hearing at Hatfield learned that Eddie Coffey had died in the neonatal intensive care unit at Luton & Dunstable Hospital on 14 January 2019, having been transferred from the Lister Hospital in Stevenage due to major complications following his birth there the previous night.

Eddie’s 30-year-old mother, Hannah Coffey from Hoddesdon, already had a two-year-old child and was seven weeks pregnant with Eddie when, on 29 May 2018, she was assessed by the Lister Hospital as low-risk as regards antenatal care.

In August, Hannah’s history was reviewed during her visit to the hospital’s Consultant Clinic. She was already taking aspirin in view of raised blood pressure during her earlier pregnancy and she was to have third-stage active management with regular blood pressure checks from 24 weeks.

Delivery

On 13 January 2019, Hannah experienced contractions and was admitted to the midwifery-led unit at the Lister. Initial monitoring at 1815 showed that the fetal heart rate was within the normal range and it remained so for over four hours as contractions became more frequent.

At 2240, a large deceleration in heart-rate was noted and the Lister’s Consultant-led unit (CLU) was informed of this. Minutes later, Hannah was transferred to the CLU and a cardiotocograph (CTG) was commenced to monitor fetal heart rate and contractions.

Over the next 10 minutes fetal heart rate was recorded as within normal range, and birth was imminent, so a request for the Registrar to attend was cancelled. Eddie was delivered just before 2330, but his condition was concerning.

Resuscitation

The emergency buzzer was used to call for resuscitation and the neonatal team took over, with the Locum Registrar on call for Paediatrics attending.

Resuscitation was provided using an IPPV ventilator, with cardiac compression, until ETT intubation was ready at 2350. Eddie’s heart rate then fell further, prompting re-intubation with a narrower tube, and his heart rate improved.

At around midnight, the Neonatal Consultant arrived and tests of venous gas indicated metabolic acidosis, a serious electrolyte disorder. Eddie was transferred to the neonatal intensive care unit (NICU), where fluids and medication were administered while ventilation continued.

Suspecting hypoxic ischemic encephalopathy (HIE), a brain damage, the consultant arranged transfer to the NICU at Luton & Dunstable Hospital for possible therapeutic hypothermia treatment. Baby Eddie was transferred there in the early hours but sadly died later that day.

Cause of death

A post-mortem at Great Ormond Street Hospital found that the cause of Eddie’s death was perinatal asphyxia.

A Serious Incident Investigation by East and North Hertfordshire NHS Trust followed. The investigation report concluded that at a crucial time in the proceedings the CTG appeared to have recorded the mother’s heart rate, not the baby’s, thus preventing recognition of fetal hypoxia. This was likewise the opinion of independent expert evidence heard by the Coroner such that earlier identification of Eddie’s condition would have improved his outcome. Such a failing, the Coroner found, amounted to neglect.

“Correct, effective use and interpretation of a baby and mother’s heart rate is helped by a CTG machine but it still needs to be interpreted responsibly and then appropriately acted upon. Here the Coroner determined on all of the evidence that it was neglect to fail to provide such basic care to Eddie and that this may have avoided such a tragic outcome,” said specialist medical solicitor Tim Deeming of Tees Law, acting for parents Hannah and Thom Coffey. “The inquest has been very challenging for the family and whilst we understand that the Lister have been looking to improve, we want to ensure that this does not arise for any other family, especially given the findings from the national Each Baby Counts review and the concerns raised around such preventable outcomes.”

Hannah’s concern for others

“Saying goodbye to our beautiful boy only hours after he had been born has left us all with a hole in our hearts from which we will never recover,” Hannah Coffey reflects.

“Not for a moment did I imagine that we could arrive at hospital with a healthy baby and leave without him in our arms. Like many expectant parents we put our trust in the care we would receive.

Knowing that a lack of competence in the use of vital medical equipment could affect other families in a similar way is driving us to raise awareness of the need to ensure proper training and use of equipment to help save the lives of other babies.”

Norfolk boy died from undiagnosed bowel condition after surgery delay

Posted on 10 February 202130 March 2025 by Sarah O'Sullivan

Norfolk Coroner’s Court has issued its conclusions in the tragic case of an eight-year-old boy from Harleston, noting that the gravity of the child’s condition and the need for surgery were not recognised by paediatric staff at the Norfolk & Norwich University Hospital.

The inquest had heard that Charlie Goodwin died at Addenbrooke’s Hospital, Cambridge, on 6 September 2019, following a move from Norfolk & Norwich, where emergency surgery had been conducted hours earlier.

In her written statement for the Coroner, Charlie’s mother, Nicola Goodwin, explained how the happy, football-mad youngest of her six children had been seemingly healthy until a vomiting episode in December 2018 followed by abdominal pains and prolonged loss of appetite.

Early in 2019, Charlie’s abdomen became distended, and the family’s GP shared his mother’s concern about this at a March 2019 consultation. Blood tests ruled out food intolerances, so further investigations began at Norfolk & Norwich University Hospital.

Concerned about worsening abdominal pain and uneaten school lunches, Nicola sought an early hospital appointment, and Charlie was seen at Norwich on 18 July and given an abdominal X-ray. The report showed large bowel dilatation, which Nicola discovered could be due to a blockage.

No follow-up hospital appointment was forthcoming, but on 25 July, Nicola took Charlie to the nurse practitioner because he was feverish with possible symptoms of a urinary infection. The nurse suggested heatstroke as the likely cause.

Symptoms intensified

Over the next few days, Charlie’s symptoms intensified, and a call to NHS111 prompted a visit to the local Beccles Hospital. Checks found nothing wrong, as did a subsequent doctor’s appointment, at which a urine sample was taken and antibiotics prescribed as a precaution.

When Charlie’s temperature hit 40.5oC the next day, and his abdominal pain became severe, Nicola suspected a blockage and took him straight to A&E, where checks for infection were negative and examination by several doctors also found nothing, so he was discharged.

Fever and pain on 2 August led Nicola to take Charlie back to Norfolk & Norwich, where a children’s emergency doctor suspected meningitis, ordering a head scan and lumbar puncture. The radiologist refused a scan, doubting the necessity, but Charlie was admitted later that day.

Overnight on 4 August, the paediatric surgeon was called; he noted Charlie’s distended abdomen and ordered an abdominal X-ray and MRI scan, though the scan never happened, and Nicola was not told why. A heart scan was done and revealed a slight murmur, but no action followed that.

‘Medical mystery’

Inconclusive abdominal ultrasounds were also taken, though Nicola learned weeks later that malrotation meant Charlie’s intestines had not formed properly. Some blood tests but no further scans were carried out before Charlie was discharged on 7 August, described as ‘a medical mystery’.

Pain and lack of appetite continued, and on 14 August, Charlie had a barium swallow test, ordered earlier, which produced a ‘normal’ result but did not cover all of the bowel. A urodynamics test followed for continence issues, which Nicola suspected were linked to the other symptoms.

Charlie returned to school in September but was not eating his packed lunches. On 5 September, he also left his dinner and began vomiting, though with nothing to bring up. A 999 call, prompted by Charlie screaming out in pain and vomiting, brought only an instruction to use her GP or out-of-hours surgery.

Charlie vomited repeatedly and continued to scream, groan and writhe in pain when driven instead to Norfolk & Norwich A&E, which sent him straight to the Children’s Emergency Department. His temperature and blood pressure were very low, and his heart rate was very high. He was put on intravenous fluids, and a surgical review was sought, but the paediatric surgical registrar was already busy.

Despite Charlie’s presentation and a doctor’s request for urgent surgical review at around 22:15hrs, it was not until midnight that the paediatric surgical registrar reviewed Charlie, noting that there was no need for surgical intervention and put forward a plan for conservative treatment. Charlie’s situation worsened throughout the night, several further requests for surgical assessment were made, and hours later, at 2am following escalation to the paediatric surgeon, the surgeon examined Charlie’s enlarged, hard, blue tummy and declared that urgent exploratory surgery was needed as the cause was unclear.

During the preparation for surgery, Nicola exclaimed that Charlie’s pupils were dilated, and a nurse found them unresponsive. Administering oxygen brought a brief reaction, but a doctor sounded the emergency alarm, and Nicola had to leave.

Cardiac arrests

A little later, a nurse came to tell a stunned Nicola that Charlie’s heart had stopped and they were responding to that. Despite two cardiac arrests, the plan for surgery stood, but Nicola was told that her very sick son might not make it.

Charlie went to the theatre at 5 am and an hour later was in recovery, a doctor telling the family he had intestinal malrotation causing a twisted bowel. Later that morning, they were told he would be transferred to the paediatric intensive care unit (PICU) at Addenbrooke’s Hospital.

A third cardiac arrest occurred as Charlie was switched to the children’s ambulance equipment, another while switching at Addenbrooke’s and a fifth after arrival in the PICU. The family were told further CPR would mean no quality of life due to brain damage and multiple organ failure.

At the bedside, the distressed family witnessed blood pouring first from Charlie’s operation wound and then his nostrils. His parents made the agonising decision not to resuscitate him after his next cardiac arrest and were there when he sadly died at 6.20 pm on 6 September.

“There were missed opportunities to give young Charlie Goodwin the timely and appropriate medical treatment that his intestinal malrotation required,” asserts specialist solicitor of Tees Law, acting for the bereaved Goodwin family.

“The final opportunity was at the Norfolk & Norwich University Hospital on that fateful evening in September last year. Prompt and effective emergency surgery could possibly have averted the catastrophic outcome that followed a delay of several hours.”

“The assessment by the paediatric surgical registrar was not acceptable, based on the clinical circumstances,” Tees law explains. “The paediatric surgical registrar did not recognise the severity of Charlie’s illness, and this error delayed the treatment, which could have saved Charlie’s life.

“Following the sad outcome, the hospital’s medical director requested an ‘invited clinical record review’ of the case by the Royal College of Surgeons. The RCS report dated 29 June 2020 formed an important part of evidence for the inquest Coroner.”

NHS Trust accepts RCS findings

The RCS review team investigated various aspects of Charlie’s treatment. Their report made recommendations to address patient safety risks and aspects of the case that pointed to a need for service improvements.

The review team was concerned about the six-hour gap before Charlie was seen by a consultant on the evening of his emergency admission on 5 September 2019. They recommended that: “To facilitate service improvement and reduce the possibility of a similar tragic, catastrophic incident, the Children’s Early Warning Score (CEWS) is reviewed and may be refined by the addition of information from blood gas (lactate) analysis to trigger an automatic senior review escalation.”

Other recommendations for action by the Trust to improve service included undertaking a review of the out-of-hours junior staff cover for paediatric surgery, reassessing the adequacy of facilities for critically ill children in the Children’s Emergency Department at Norwich, and ensuring that information in clinical notes avoids judgmental language and remains factual.

Having received and read the RCS report, on 30 June, the Trust’s medical director sent Charlie’s parents a copy with a letter expressing sincere and heartfelt apologies and condolences and assuring them that the Trust accepted the review conclusions in full and was working hard to address them.

The letter also said, “The key conclusion that stands out to me, and I am sure it will to you also, is that the assessment made of Charlie on 5 September 2019 by the paediatric registrar was not acceptable and that there was a missed opportunity to discuss Charlie’s care in a more urgent manner with the paediatric consultant. The investigation has concluded that had there been a more urgent response, there may have been an opportunity to save Charlie’s life.”

Life could have been saved

This position was reiterated on the Trust’s behalf during the current hearing by the consultant paediatrician, who agreed that the paediatric registrar’s assessment was unacceptable and acknowledged that ‘the level of care we normally provide and that Charlie deserved was not provided that night’.

Under questioning by Counsel, the consultant accepted that the registrar failed to recognise the severity of Charlie’s illness as evidenced by blood gases, delaying by several hours emergency surgery that could have saved his life, particularly if he had been taken to theatre before his first cardiac arrest.

Inquest Conclusions

The Coroner’s conclusions were: “Charlie had a history of abdominal distension and vomiting. He had several admissions to hospital and underwent extensive examinations and tests. He was admitted to Norfolk and Norwich University Hospital on 5 September 2019 presenting as very unwell and in shock. During late 5 September 2019 Charlie was reviewed from a surgical perspective, and the gravity of Charlie’s condition and the need for surgery were not recognised. Surgical advice was not sought from the on-call Consultant.

“Charlie’s condition deteriorated further, and it was not until it was re-escalated to the medical team that the need for surgery was recognised. Charlie did not undergo surgery until the early hours of 6 September 2019, when an emergency laparotomy was performed. Charlie’s condition remained serious. Later that day, he was transferred to Addenbrooke’s Hospital, where his condition continued to deteriorate, and he died. Charlie Goodwin died from a rare and undiagnosed bowel malrotation and midgut volvulus.”

Under her Regulation 28 duty to prevent future deaths, the Coroner has noted that she will write to the General Medical Council, inviting them to have a recording of the inquest and informing them that they may wish to investigate the paediatric surgical registrar’s evidence and fitness to practice.

Having heard the Inquest outcome, Tees Law said, “Had Charlie been assessed properly, it is likely that he would have been taken to surgery much earlier, well before his condition deteriorated further and he suffered from a cardiac arrest. Had that been the case, Charlie’s chances of survival would have been much greater, and it is likely that his life would have been saved.”

Tees Law added, “Charlie’s mum Nicola and the whole family are desperate to ensure this never happens to anyone else. They are devastated by the loss of their wonderful, incredibly loving and funny son and brother. They want to raise general and medical awareness of this rare condition and hope to do so in Charlie’s memory.”

Bright graduate died after GP practice dosage error

Posted on 28 January 202130 March 2025 by Sarah O'Sullivan

West Sussex Assistant Coroner Ms Henderson has concluded an Inquest into the tragic death of a 30-year-old man who had been receiving medication for severe back pain at a village medical practice. It points to shortcomings in the treatment given by the practice in Loxwood.

This week’s hearing and an adjourned hearing at Crawley in January learned that Leeds University graduate Hamish Hardie died in August 2019 at the family home in Wisborough Green from an accidental overdose of prescribed painkillers, for which the dosage label was unclear.

Hamish required pain relief for severe back pain caused by two prolapsed lumbar vertebral discs, for which he was waiting for private surgery, and was dealt with at Loxwood by a qualified doctor who was in his final year of GP training under the supervision of a senior GP.

Dosage not specified

The doctor prescribed two opiate painkillers, Dihydrocodeine and Oramorph, as well as the relaxant Diazepam. The prescription for the Oramorph on the label tragically said it should be taken as directed, which was unclear. Sadly, this was also not identified by the dispensing practitioner within the pharmacy at the practice.

Hamish’s mother Mary-Anne took responsibility for administering the medication, but the uncertainty about the Oramorph label and reliance on Hamish for dosage details meant that more frequent and higher doses were given.

Sadly, Hamish died two days later and a post-mortem confirmed that the primary cause was a prescription drugs overdose, which the Coroner concluded was accidental. The trainee and supervising GPs did not recall seeing an alert on the medical records and the computer system meant that with an Oramorph prescription its labelling default standard was ‘use as directed’.

“We still feel that Hamish was badly let down that day and that his life was unnecessarily cut short by medical failings,” Mary-Anne Hardie reflects. “It was May 2019 when Hamish developed back pain from a suspected slipped disc. That was confirmed on an A&E visit in June, when he was given Diazepam and put on the list for a possible operation. We are disappointed that the GPs did not see the alert on the computer and that if the labelling and prescription advice had been clear, or the pharmacy had spotted the inconsistency, then we feel that Hamish would still be here as he was looking forward to job interviews and a new chapter in his life.”

A ‘perfect storm’

Specialist solicitor Tim Deeming of Tees Law adds: “The Coroner described this as a perfect storm and it is tragic that the GPs did not know that the labelling system defaulted, and that the pharmacy did not then spot this.

“While we are glad to know that the Loxwood Medical Practice has made significant changes to procedures following Hamish’s death we all hope that the NHS and GPs will take steps when providing such prescriptions to provide clear guidance on use, as well as checking computer systems to ensure that other families do not have such devastating outcomes.”

Widow secures six figure sum after 5 year delay in diagnosing husband’s brain tumour

Posted on 17 December 202028 March 2025 by Sarah O'Sullivan

Nick’s Tragic Story: A delayed diagnosis and its consequences

Nick suffered a massive stroke when doctors attempted to remove a tumour that should have been diagnosed and treated several years earlier. Tragically, he passed away a few years later from a cardiac arrest.

Pursuing a Medical Negligence Claim

Janine Collier, Partner in Tees’ medical negligence team, supported Nick’s widow in pursuing a claim against Nick’s optician and ophthalmologist. The claim was based on a delay in investigating a visual field defect, a known indicator of a brain tumour.

A life full of promise

Nick, a man in his 40s, was fit, healthy, and happily married to Barbara. He had always worked hard to provide for his family, and together, they looked forward to a long and fulfilling retirement.

However, their plans were shattered when Nick was diagnosed with a brain tumour and subsequently suffered a catastrophic stroke due to surgical complications.

The initial warning signs

Years before his diagnosis, Nick visited his local optician for blurred vision in one eye. After conducting a visual field test, the optician diagnosed him with a lazy eye. Despite Nick’s concerns, the optician referred him to the ophthalmology department at his local hospital.

The ophthalmologist concluded that Nick had impending presbyopia, a common age-related vision condition, and discharged him without further investigation.

A devastating diagnosis

More than five years later, Nick experienced blurred vision, speech difficulties, and weakness in his arm and leg. Brain imaging revealed a pituitary adenoma, a brain tumour pressing on critical structures.

As Nick’s condition worsened, he underwent surgery to remove the tumour. Due to its size and invasiveness, only a partial removal was possible. Sadly, during a subsequent surgery, Nick suffered a major stroke, causing permanent damage.

Living with the aftermath

The stroke left Nick with severe mobility and vision impairments. No longer able to work, he relied heavily on Barbara for care. Despite these challenges, the couple faced their new reality together.

Unexpectedly, Nick passed away four years later from a heart attack.

How Tees supported Nick and Barbara

Nick and Barbara were devastated by the diagnosis and its consequences. They suspected the tumour should have been identified sooner and approached Tees for legal advice.

Janine Collier said, “When I met Nick and Barbara, I was struck by their resilience and devotion to each other. I wanted to help them understand what had happened and ensure they had financial security for the future.”

After reviewing the evidence, Janine discovered that the optician had detected a visual field defect—a clear sign of a brain tumour. However, this critical information was not relayed to the ophthalmologist, who failed to investigate further.

Had the tumour been diagnosed earlier, it would have been smaller, making surgery less complex and preventing the stroke. Nick would have retained his vision and avoided the life-altering consequences.

Seeking justice

Both the optician and the hospital denied liability, leading to court proceedings. The case was eventually settled after Nick’s passing.

Barbara later expressed her gratitude: “You really have made things as painless as possible, Janine. It’s been hard without Nick, but I know he’d be pleased that I don’t have to worry financially and can support our daughters.”

Compassionate legal support from Tees

At Tees, we understand the emotional and financial toll of medical negligence. Our experienced clinical negligence lawyers are here to provide compassionate support and guide you through every step of your claim, from the initial consultation to achieving a financial settlement.

If you believe you or a loved one have suffered due to medical negligence, contact our team today to discuss how we can help you seek justice.

Tees secured a six figure settlement after client told of miscarriage and ectopic pregnancy overlooked

Posted on 28 October 202028 March 2025 by Sarah O'Sullivan

Devastated by delayed diagnosis: Emma’s ectopic pregnancy misdiagnosis claim

Emma was left heartbroken when a delay in diagnosing her second ectopic pregnancy resulted in the removal of her remaining fallopian tube, leaving her infertile. With the compassionate support of Gwyneth Munjoma, a solicitor in Tees’ Clinical Negligence team in Chelmsford, Emma pursued a successful medical negligence claim against the NHS Trust responsible for her care.

A hopeful start turned tragic

Emma and her husband Simon had been eager to start a family. After experiencing two pregnancy losses, including one due to a previous ectopic pregnancy that required the removal of one fallopian tube, the couple remained hopeful. With only one remaining tube, they were determined to grow their family, though the fear of further complications lingered.

Following her first ectopic pregnancy, Emma received clear medical advice: if she became pregnant again, she should seek immediate medical attention for close monitoring.

Misdiagnosis and missed opportunities

When Emma discovered she was pregnant once more, she quickly attended the hospital. At five weeks pregnant, she reported slight vaginal bleeding but no pain. She was reassured and scheduled for a follow-up scan in five days. Despite her concerns, doctors advised her to return only if her symptoms worsened.

At her next scan, no embryo was detected in her womb. Despite a positive pregnancy test, doctors concluded that she had miscarried. Emma was instructed to undergo blood tests every 48 hours to monitor her hormone levels. To her confusion and distress, each test confirmed that her hormone levels were rising, indicating an ongoing pregnancy.

A devastating diagnosis

Four days after her third hospital visit, Emma began experiencing severe abdominal pain and significant bleeding. She rushed to A&E, where further scans revealed the heartbreaking truth — she was experiencing a second ectopic pregnancy. Her only remaining fallopian tube had ruptured, necessitating emergency surgery to remove it. The procedure left Emma unable to conceive naturally.

Pursuing justice with Tees

Struggling to come to terms with their loss, Emma and Simon approached Tees for legal advice. Gwyneth Munjoma took on their case, determined to uncover what went wrong. Independent medical experts confirmed that Emma’s care had fallen below acceptable standards. Had her ectopic pregnancy been diagnosed earlier, appropriate treatment could have preserved her fertility.

Faced with overwhelming evidence, the NHS Trust admitted full liability for the failings in Emma’s care. Gwyneth successfully negotiated a six-figure settlement, providing Emma and Simon with the financial means to explore alternative fertility options.

Supportive and experienced legal guidance

At Tees, we understand how deeply personal and emotional medical negligence claims can be. Our experienced clinical negligence solicitors are here to provide compassionate, expert legal support to those who have suffered from misdiagnosed ectopic pregnancies and other medical errors.

If you believe your medical care has fallen below standard, we’re here to help. Contact Tees for a confidential consultation and let us guide you through the process of making a medical negligence claim.

All names have been changed to protect confidentiality.

Misdiagnosed ectopic pregnancy resulted in major emergency surgery

Posted on 27 October 202029 March 2025 by Sarah O'Sullivan

Carol suffered a ruptured ectopic pregnancy after her symptoms were wrongly treated as a urinary tract infection.

Gwyneth Munjoma, solicitor in Tees’ clinical negligence team, helped her client to pursue a claim against the NHS Trust after her fallopian tube ruptured and had to be removed.

Carol and David were ecstatic when they discovered that she was pregnant. Like most modern-day women, to avoid any doubt and in a bit of disbelief, Carol carried out a few home pregnancy tests which were all positive. Things were going well until Carol was about 4-5 weeks pregnant. Out of the blue, she developed very severe pain in her lower tummy on the right side, her right shoulder tip and her rib cage. Her tummy also felt very bloated. Worried about this, Carol immediately attended A&E at her local hospital where she clearly described her symptoms and informed the triage nurse and the doctors that she was about 4 -5 weeks pregnant.

Sent home without adequate advice

Despite having no signs or symptoms of a urine infection, Carol was advised that she most likely had a urinary tract infection. The doctors completely ignored the fact that she was pregnant so failed to consider that the symptoms she had could be of an ectopic pregnancy (ectopic pregnancy occurs when a fertilised egg attaches itself somewhere outside of the womb (usually in the fallopian tube) and begins to grow). Carol was discharged home on a course of oral antibiotics with an extra course of antibiotics to take if after completing the first course the “urinary tract infection” did not resolve. Carol was not given any advice about watching out for the symptoms of ectopic pregnancy and returning to be checked if the antibiotics did not resolve her symptoms.

At home, Carol took the antibiotics as prescribed but continued to experience the same amount of pain. As advised by the A & E doctor when her pain did not resolve after completing the first course of antibiotics, she went on to take the second course of antibiotics.

HSIB found that a failure to adequately escalate care in pregnant mothers was a recurring theme in their 2021/22 Maternity Investigations.

With the symptoms that Carol had described, it is expected that a referral to a specialist early pregnancy assessment clinic and an ultrasound scan to confirm her pregnancy plus follow up blood tests every 48 hours would have been arranged

About two weeks later Carol suddenly experienced excruciating pain in her tummy, and pain in her ribs and shoulder. She felt nauseous, went pale and was shivering and sweating. Painkillers did not relieve her pain. She made an emergency appointment with her GP who suspected a ruptured ectopic pregnancy. The GP immediately arranged for an ambulance and Carol was blue lighted to a hospital different from the one she had originally attended. At the hospital, Carol was informed that she had suffered a ruptured ectopic pregnancy, was in a state of shock and needed to be operated on immediately. She was rushed to the operating theatre where severe bleeding in her tummy obstructed the surgeon’s view. The keyhole surgery was therefore turned into an open tummy operation. Her fallopian tube was removed, and she required a blood transfusion.

Carol found herself in a frightening and life-threatening emergency. She was devastated not only to have lost her much awaited baby, but also her fallopian tube, potentially affecting her future fertility.

How we helped

Carol and David contacted our medical negligence team as despite starting to process and recover from their traumatic experience they found themselves questioning the quality of care and attention Carol had been given by the healthcare professionals who had attended to her.

Gwyneth Munjoma, solicitor in Tees’ clinical negligence team, Tees Said “looking at Carol’s situation, I wanted to help Carol and David understand what had gone wrong and how her care could have been better, in the hope that lessons would be learned from Carol’s experiences and that no one else would face the same situation that she had in the future”

Carol made a complaint against the NHS Trust which was upheld.

Gwyneth gathered evidence and sought independent expert medical advice to support Carol’s claim. The independent medical expert advice as to the standard of care and treatment that Carol ought to have received which would have saved her fallopian tube. The expert further advised that if Carol had been given proper care and treatment, not only would her fallopian tube have been saved but also that she would have avoided the major surgery and the life-threatening situation that she found herself in.

A legal claim was then made against the NHS Trust. In response, the Trust admitted full liability for the substandard care accorded to Carol and the consequences of that substandard care.

Gwyneth negotiated a settlement for Carol who received enough compensation to enable her to access treatment to help her come to terms with what had happened and to positively plan for her future.

The care that Carol received raised several questions and the Trust’s early admission of liability was a welcome acknowledgement of what had gone wrong with the care given to Carol.

Caring and sensitive support with Tees

Whatever your situation, our legal specialists are here to help guide you. Our expert clinical negligence lawyers will handle your ectopic pregnancy misdiagnosis claim from the initial consultation through to financial settlement.

*All names changed for confidentiality

Timely treatment might have saved devoted wife and grandmother

Posted on 26 October 202030 March 2025 by Sarah O'Sullivan

A retired wife and grandmother tragically died in hospital after multiple opportunities were missed to administer appropriate treatment that could have saved her life, an inquest at the Suffolk Coroner’s Court in Ipswich concluded after a two-day hearing.

HM Senior Coroner for Suffolk, Nigel Parsley, heard that 61-year-old grandmother Karen ‘Jane’ Winn from Northwold near Thetford, Norfolk, died at the West Suffolk Hospital in Bury St Edmunds on Monday 15 April 2019, four days after being diagnosed with a suspected urinary tract infection by her GP.

Jane was prescribed antibiotics by her GP on 11 April, but she returned next day as she was by then very unwell. She was referred straight to hospital and admitted the same day. That evening a senior medical consultant diagnosed Jane’s condition as haemolytic anaemia, a serious blood disorder.

Haemolytic anaemia depletes oxygen-carrying red blood cells and medical staff identified that Jane was at risk of developing a deep vein thrombosis, which can result in a life-threatening pulmonary embolism if a blood clot reaches the lungs. So, correct intervention at that point was vital for Jane.

Once the haemolytic anaemia diagnosis had been made, the immediate response should have involved blood transfusions plus ‘prednisolone’ steroids and folic acid. Anticoagulant medication was intended to be given, subject to the result of a repeat blood test to assess internal bleeding risk.

Anticoagulant delayed

Jane initially received only blood transfusions and antibiotics. Not until 14 April were steroids and folic acid administered, whilst no prophylactic anticoagulant was given until 15 April, by which time it was too little, too late to disperse any blood clots that had formed during the previous 72 hours.

An automated venous thromboembolism (VTE) risk assessment warning system is embedded into the electronic patient monitoring for all patients. Disturbingly, this VTE system was manually overridden 58 times between 12 and 15 April, despite Jane’s increased risk of blood clots.

Sadly, soon after transfer to the intensive care unit and an hour after her first and only dose of anticoagulant, Jane suffered a fatal cardiac arrest. This was the outcome that Jane’s distraught husband Brian and the wider family had feared and one they believe could have been avoided.

“We are bitterly upset that such an essential part of the treatment available for Jane’s illness wasn’t used promptly,” says a close family member. “The right diagnosis was made, but life-saving medication was given too late, despite repeated reminders. Our hope now is that lessons learned will prevent the same thing happening to anyone else.”

Significant blood clots

The primary cause of death, a bilateral pulmonary embolism, with deep venous thrombosis and haemolytic anaemia as contributory causes, was confirmed at post-mortem. Widespread pulmonary emboli in the lungs and significant blood clots in veins of the upper leg were both evident.

In summary, the Coroner concluded that Jane’s death resulted from the progression of a naturally occurring illness, contributed to by the non-administration of medication to prevent blood clots despite being earlier identified as essential for her treatment; the latter amounted to neglect.

Tees Law, acting for the bereaved family, comments: “A venous thromboembolism risk assessment is mandatory for all patients admitted to hospital and should be completed within hours of admission. It was wholly unacceptable for the assessment alert to have been overridden 58 times over those four days. The Coroner’s finding of neglect acknowledges the total failure to give Jane basic medical treatment that would ultimately have increased her chances of survival.”

Read the full story here.

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Alleged delays in diagnosis and treatment of sepsis following gallbladder surgery

Posted on 9 September 202028 March 2025 by Sarah O'Sullivan

Alison’s experience with sepsis sfter gallbladder surgery.

Alison* underwent a laparoscopic cholecystectomy (keyhole surgery) to remove her gallbladder at a private hospital. Although the surgery seemed successful, Alison developed sepsis in the days that followed. Four years later, she continues to experience its effects and remains unable to return to full-time work as a dental nurse.

Early signs of sepsis ignored

Following her discharge, Alison quickly became unwell. She experienced severe abdominal pain, shakiness, nausea, and bruising on her abdomen. Despite contacting the hospital multiple times, her concerns were dismissed. Her condition deteriorated significantly before she was eventually readmitted for observation.

Failure to diagnose sepsis

At the hospital, Alison displayed classic symptoms of sepsis, including a high temperature, increased heart rate, and a raised white blood cell count. However, the hospital’s Sepsis Screening and Action Tool was not followed, and no diagnosis of sepsis was made. Instead, the doctor concluded that there was “probably not a serious abdominal complication.”

An ultrasound scan was performed the next day, but this test alone was insufficient to diagnose or rule out infection. A CT scan, which would have been more appropriate, was not conducted at this stage.

Continued deterioration and delayed treatment

Despite her worsening condition, Alison did not receive a clinical review on the sixth day post-operation. Although antibiotics were eventually administered, they came too late to prevent further complications.

On the seventh day, a CT scan confirmed the presence of infection. However, Alison’s doctor reassured her that it was not serious. By the eighth day, she collapsed, and one of her keyhole wounds burst. Emergency surgery was finally carried out on the ninth day to drain a massive abscess.

Escalation and further treatment

Alison’s condition remained critical. She required urgent transfer to an NHS hospital, where she underwent additional procedures to manage the infection. She spent time in the High Dependency Unit, endured further surgeries, and required multiple abdominal drains.

Ongoing impact on Alison’s life

Alison’s recovery has been slow and challenging. Her primary wound was left open, and she experienced long-term fatigue, anxiety, and depression. Despite her dedication to her profession, she has been unable to return to full-time work.

The psychological trauma of her ordeal, including a fear of death and health-related anxieties, has also had a profound effect on her daily life.

Seeking legal support

When Alison approached us, we identified two main areas of concern:

Delayed diagnosis and treatment: Alison exhibited clear signs of sepsis, yet these were ignored for days.
Effectiveness of subsequent treatment: The delay in draining the infection may have worsened her condition.

Had sepsis been promptly diagnosed and treated, Alison may have avoided her collapse, emergency transfer, and the need for further invasive procedures.

Raising awareness about sepsis

Alison is now passionate about raising awareness of the importance of early diagnosis and treatment of sepsis. In support of World Sepsis Day, she hopes her story can prevent others from enduring a similar experience.

Expert opinion

Katheryn Riggs, Associate in the Medical Negligence team at Tees, stated:

“The consequences of delaying the diagnosis and treatment of sepsis can be fatal; 20% of deaths worldwide are associated with sepsis. Time is of the essence to halt the patient’s deterioration and to maximise the best chances of recovery.”

How our sepsis negligence solicitors can help

Professional guidelines on sepsis diagnosis and treatment are clear, but errors still occur. When negligence leads to harm, we can help.

You may have a claim if:

Your diagnosis was delayed, leading to further complications.
You were misdiagnosed, resulting in inadequate or delayed treatment.

Our experienced solicitors are here to listen, support, and provide expert legal advice. We’ll help you get the answers you deserve.

*Name changed to protect client confidentiality.

Weight loss surgery (or bariatric surgery): Medical negligence claims

Posted on 2 September 202024 March 2025 by Sarah O'Sullivan

Bariatric surgery is recognised by NICE as one of the most cost-effective healthcare interventions to reduce the risk of obesity-related diseases and death.

NHS statistics on obesity, physical activity, and diet (published on 5 May 2020) show a consistent increase in hospital admissions directly attributable to obesity since 2014. Similarly, the number of obesity-related bariatric surgery admissions in the NHS has risen. The primary goals of surgery are significant weight loss and the improvement or reversal of obesity-related conditions, such as high blood pressure and type 2 diabetes.

Despite the increasing number of procedures performed on the NHS, many patients ineligible for NHS treatment choose to pay for private bariatric surgery

Weight-loss surgery and medical negligence claims

While bariatric surgery is often an effective solution for weight management, it requires a lifelong commitment to lifestyle changes for lasting results.

Surgical procedures carry inherent risks, and mistakes can have serious, life-changing consequences. If you believe negligent treatment has caused you further suffering, or if you were inadequately informed about potential complications, you may be eligible to bring a claim within three years of the negligence. Our expert solicitors can guide you through the process.

Sarah Stocker, Solicitor in Tees’ Medical Negligence Team, explains the risks and complications that can arise from bariatric surgery.

Considerations before surgery

Weight-loss surgery is typically considered if:

You have a body mass index (BMI) of 40 or more, or a BMI between 35 and 40 with a serious health condition that could be improved by weight loss.
You have tried non-surgical treatments (e.g., dietary improvements and exercise) for at least six months without significant success.
You are healthy enough to undergo the surgery.
You commit to long-term follow-up treatments and lifestyle changes.
You undergo a psychological assessment to evaluate your suitability and motivation.

Types of bariatric surgery

Bariatric surgery involves altering the digestive system to reduce food intake and promote weight loss. Common procedures in the UK include:

Gastric band insertion: An adjustable silicone band is placed around the stomach to create a small pouch. It reduces the amount of food needed to feel full. The band can be adjusted using a small device under the skin.
Gastric bypass: The upper part of the stomach is stapled to create a small pouch, which is connected to the small intestine, bypassing the rest of the stomach. This reduces calorie absorption and increases fullness.
Sleeve gastrectomy: A large portion of the stomach is removed to create a smaller stomach. This procedure is irreversible, and long-term data on weight regain is limited.

Risks of bariatric surgery

When considering surgery, it is essential to weigh the risks of the procedure against the long-term health risks of severe obesity, including strokes, heart attacks, cancer, and diabetes. Common risks include:

Infection
Anaesthetic complications
Blood clots in legs or lungs
Internal bleeding
Damage to internal organs
Nutritional deficiencies
Gallstones from rapid weight loss
Psychological challenges, including depression or self-harm

Informed consent process

A comprehensive informed consent process is crucial. Your surgeon should explain the specific risks and benefits of the procedure, as well as any patient-specific concerns.

Gastric band insertion: Patients should be informed about the need for multiple adjustments, the risk of infection at the band or port site, tubing issues, and the potential for band slippage or erosion.
Gastric bypass: Patients should understand the risk of dumping syndrome, anastomotic leaks, and internal herniation, along with the requirement for lifelong vitamin supplementation and regular blood tests.
Sleeve gastrectomy: Patients should be made aware of the irreversible nature of the procedure and the risk of staple line leakage.

Additionally, all patients should be advised about the possibility of weight regain and the likelihood of loose skin, which may require plastic surgery.

Common bariatric surgery negligence claims

Negligence claims may arise from:

Substandard surgical performance
Failure to promptly diagnose or treat post-operative complications, such as infections or malnutrition
Delayed recognition and treatment of internal organ damage
Incorrect gastric band placement leading to blockages or additional procedures
Mismanagement of band slippage
Incomplete gastric bypasses or staple line issues causing leaks
Delayed identification of leaks leading to severe complications and further surgery

Compensation for negligence

In addition to compensation for physical and psychological injuries, claims may cover financial losses and expenses, including:

Loss of earnings
Transport costs
Private medical expenses
Care, support, and assistance costs

Making a Medical Negligence Claim

We understand that making a complaint about medical treatment can be overwhelming. However, pursuing a claim can provide financial support and hold negligent providers accountable. If you have suffered injury or financial loss, we are here to help you navigate your claim.

Contact our expert team of solicitors today for guidance and support.

NHS Early Notification Scheme (ENS)

Posted on 20 July 202024 March 2025 by Sarah O'Sullivan

The NHS Early Notification Scheme investigates the events surrounding the birth of a child who has suffered potentially severe brain injuries (most commonly cerebral palsy) at birth.

This process means families can find out what happened and why relatively quickly after birth. An advantage of proceeding under the ENS is that the facts are fresh in everyone’s minds and it reduces the stress for the family. Where negligence by clinical staff is established, an apology is offered to the family and financial support and advice are given to help them care for their child throughout the child’s lifetime. Read more about the NHS Resolution Early Notification Scheme.

Does the Early Notification Scheme cover all brain injuries at birth?

No. Not all cerebral palsy cases fall within the Early Notification Scheme – the Scheme is limited to those that fall within the reporting criteria and guidelines. There are three categories that the ENS can work on:

grade 3 Hypoxic Ischaemic Encephalopathy (HIE) – which is if the baby’s brain is deprived of sufficient oxygen and blood flow;
babies who were therapeutically cooled by a clinician using active cooling – this can prevent HIE by lowering the baby’s temperature to 33 degrees Celsius; and
circumstances in which the baby is comatose or has seizures or has hypotonia (decreased muscle tone), which can cause them to be ‘floppy’.

Information about the categories are available on the NHS Resolution website.

Birth injury claims that fall outside of this scheme take many more years to investigate. In introducing the Early Notification Scheme, NHS Resolution acknowledges the need for families to avoid going through a lengthy and stressful legal process.

Is cerebral palsy covered by the Early Notification Scheme (ENS)?

Cerebral palsy is a common birth injury in the UK, but it is complex to diagnose its cause. Cerebral palsy may be diagnosed as a result of one of the circumstances listed in the three ENS categories, but at least one of those must be present for the ENS to apply.

Cerebral palsy is caused by an injury to the brain which can occur: if the brain fails to develop normally in the womb; or if there is a problem during the birth, or just after the baby is born. Establishing the precise cause of cerebral palsy is complex, and you should always seek specialist legal advice if your child has suffered a brain injury around the time of his or her birth.

What if my child’s case is not eligible for the Early Notification Scheme?

If this has happened, it is because the brain injury that your child suffered at birth, wasn’t within one of the three categories that the ENS covers. However, this is not a barrier to making a medical negligence claim.

Call us so we can help you find out what happened, and if there are grounds for a medical negligence case, claim for financial compensation to support you and your child.

Get specialist, independent legal advice

NHS Resolution expects families to seek independent legal advice. We strongly advise that if you have a baby injured at birth, you seek professional specialist legal advice as soon as possible. This is a complex area of law and you will need expert support to navigate it effectively. Our lawyers at Tees can provide you a wide range of support and guidance during the process.

Working out the extent of the brain damage your child has suffered and how that might change in the future is complex. Our legal experts work alongside some of the leading healthcare and accommodation experts in the country to make sure all future eventualities are considered. Our aim is to secure a full financial compensation package to ensure your child’s future needs are met and he or she can achieve his or her full potential.

Funding your claim

Our specialist solicitors will provide an initial free assessment of your claim. We work on a no win, no fee basis or arrange legal aid (where possible), so there’s no need to worry about costs.

How does compensation help?

If your baby has sustained a brain injury, this is of course extremely upsetting. While compensation cannot directly make that better, it can help immensely with the practicalities of day-to-day life. Once funds have been secured, you can pay for the care you child will need, which is likely to include:

medical treatment and/or physical therapies
a package of care
equipment, such as a wheelchair or specialist computers for communicating
building work to adapt your house so it is suitable for your child’s needs, so that they can move around freely as they grow older.

Our lawyers work with case managers who will ensure your family has access to support in the community. We can liaise on your behalf with a range of providers who can provide care, rehabilitation and general support; these include a range of charities and public and private care facilities.

Financial support all in one

At Tees we have independent financial advisers who can advise on the management of the compensation fund to make sure there are sufficient assets to provide lifelong care and support for your child. With expert management, the funds can be managed to ensure they don’t run out.

If your child is unlikely to be able to manage their financial and legal affairs in the future, they will need a Court appointed Deputy. This is something we can help with.

We can also help you set up a Personal Injury Trust to manage the money and protect any family entitlement to means tested benefits. If you would like us to, one of our specialist lawyers can be a trustee of this trust (alongside you) so we can continue to support you as you make future decisions.